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77 ^�^ -� APPLICATION FOR SANITARY PERMIT <br /> DILHR �L�au, COUNTY <br /> (PLB 67) <br /> oeggqnnan,'ap UNIFORM SAN TARY PERMIT # <br /> E <br /> InIXlSTq lEnT R6HllrrKin RELHTIOnS l���J �i, �q 3� <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR RTV WNE MAILING A DRESS <br /> _S_ arnw SG LL / .3S c <br /> PROPERTY LOCATION CITY: + ' <br /> St 1/4SL1/4, S � , T (?N, R / (or) W OWN OF: N ! C' <br /> LOT NUM ER BLOCK NUMBER SUBDIVISION NAME NEARHT ROAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> All / /✓ / c �.; 4 /-- E D /a r) <br /> TYPE OF BUILDING OR USE SERVED <br /> 59�1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> Q New System ❑ Tank Replacement ❑ Repair <br /> IM Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit Holding Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # issued <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity V v <br /> Manufacturer: <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage s stem shown on the attached plans. <br /> N ,oTemrb\r PriI{n—t,: MPMPRSWNo.: Phone Number: <br /> -7 4& <br /> Y/i <br /> Plumber's AdQQ�(�5esss:''yrs oq 2 Na�IJ��f D1es�ign�er: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sigr�ture of Issuing Agent: Fee: Date: ❑ Disapproved <br /> / i / n i /_ , r� r l� Owner Given Initial <br /> r Lir - �L�LL,SGC !L e�,' / °' .� 'F3l APPraved Adverse Determination <br /> eason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD 6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />